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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) f Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance withSan Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. II Job Address 9110 Thnrhton Road City qtnr-kton Lot Sizes 40 1 GQ' PM I Owner's Name South]-and rc)rP- Address5 F —2 711 Contractor's Name License No. 4 3 4 3 4 3 Phone — 7-48 TYPE OF WELL/PUMP: NEW WELL L21 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 50 SEWER LINES 2 DISPOSAL FLD._ ? PROP. LINE 1 . ;I1 FOUNDATION 1 -f t AGRICULTURE WELL 20 Qft OTHER WELL-Q..QLt_.PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �) tin. ❑ Industrial - 171 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing k1 Domestic/Private x V Gravel 1�Pack ❑ Tracy Type of Casing PVC Specifications • 0201n. a ❑ Public ❑ Other ❑ Delta Depth of Grout Seall0 f t.min, Type of Grout Cement ❑ Irrigation 4k pprox. Depth ❑ Eastern Surface Seal Installed by Sierra Pacific Drilling Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 !I. Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a'�depth of 3 feet: Water table depth SEPTIC TANK If ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I� ❑ Depth Size Number SUMPS 'll ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .I'; ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: '„'1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californla.'f The applicant must call for all required inspections. C plete drawing on reverse side. Signed X Title: Pr_0 j -r_t Ce ologist _ Date: =5-21 — I� P ENT USE ONLY h ' Application Accepted b Date A Pit or Grout Ins b Date•Final Inspection by Date Additional Comments:IE f ❑ Stk 466-6781 II ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 835-6366 ¢ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I� INFO AMOUNT DUE AMOUNT REWTTED 'C"ASH RECEIVED BY DATE tS J�PPEERMIT"NO. +EH 13-24IREV.10183? I� U �!//'S •�•J —d ri �� EH 14-28 s i